AE drugs ICU ( Phenobarbital missing)

Antiepileptic Drugs in ICU: IV vs Non-IV

Drug (Generic)	Brand	IV?	Primary ICU Role	Key Contraindications / Cautions
Levetiracetam	Keppra	Yes	First-line adjunct; broad spectrum; safe hemodynamics	Renal impairment (dose adjust); behavioral effects
Valproate	Depacon	Yes	Broad spectrum; myoclonus	Severe liver disease, pregnancy, hyperammonemia
Phenytoin / Fosphenytoin	Dilantin / Cerebyx	Yes	Convulsive status epilepticus; focal	Bradycardia, AV block, hypotension; arrhythmia risk
Lacosamide	Vimpat	Yes	Focal; easy IV loading	PR prolongation/AV block; cardiac monitoring
Phenobarbital	Luminal	Yes	Refractory status; sedation	Respiratory depression; hypotension; porphyria
Benzodiazepines	Lorazepam/Diazepam/Midazolam	Yes	First-line emergent seizure control	Resp depression; hypotension; oversedation
Topiramate	Topamax	No	Maintenance/adjunct	Metabolic acidosis; nephrolithiasis; glaucoma
Oxcarbazepine	Trileptal	No	Focal maintenance	Hyponatremia; cross-reactivity with carbamazepine
Carbamazepine	Tegretol	No	Chronic focal control	Hyponatremia; marrow suppression; drug interactions
Lamotrigine	Lamictal	No	Long-term adjunct; mood benefit	SJS/TEN risk; must titrate slowly
Zonisamide	Zonegran	No	Adjunct broad spectrum	Sulfa allergy; metabolic acidosis; renal stones
Gabapentin / Pregabalin	Neurontin / Lyrica	No	Neuropathic pain; adjunct	Renal dose adjust; sedation
Perampanel	Fycompa	No	Adjunct; GTC	Psych/behavioral adverse effects

Click to expand dosing/contraindications/ICU notes

Levetiracetam (Keppra)

Dosing (IV/PO): load 1–3 g IV once (commonly 1.5–2 g); maintenance 500–1500 mg q12h; max ~4.5 g/day; renal adjust.
Contraindications/Cautions: renal impairment (lower dose); behavioral effects (agitation/psychosis).
Primary benefits: broad spectrum, minimal interactions, stable hemodynamics.
ICU notes: excellent first add-on; safe with pressors/TTM.

Valproate (Depacon)

Dosing (IV/PO): load 20–40 mg/kg IV; maintenance 15–60 mg/kg/day divided q8–12h; target level 50–100 (up to 125 in ICU if needed).
Contraindications/Cautions: severe hepatic disease, pregnancy, mitochondrial disorders; risk hyperammonemia/pancreatitis; check LFTs, ammonia, platelets.
Primary benefits: generalized/myoclonic control; mood benefit; non-hypotensive.
ICU notes: avoid if hepatic failure or unexplained hyperammonemia; consider L-carnitine if ammonia rises.

Phenytoin / Fosphenytoin

Dosing: phenytoin load 15–20 mg/kg IV (rate <= 50 mg/min); fosphenytoin load 15–20 mg PE/kg IV (rate <= 150 mg PE/min). Maintenance 4–6 mg/kg/day divided; target total level 10–20 mcg/mL.
Contraindications/Cautions: bradycardia, AV block; hypotension/arrhythmias with rapid infusion; purple-glove risk (phenytoin).
Primary benefits: convulsive status epilepticus (after benzo); focal seizures.
ICU notes: prefer fosphenytoin IV for safer infusion; monitor ECG/BP; many drug interactions (enzyme induction).

Lacosamide (Vimpat)

Dosing (IV/PO): load 200–400 mg IV; maintenance 100–200 mg q12h (max 400 mg/day).
Contraindications/Cautions: PR prolongation/AV block, baseline conduction disease, concurrent PR-prolonging drugs.
Primary benefits: clean interaction profile; useful add-on in focal status.
ICU notes: place on telemetry during load and titration.

Phenobarbital (Luminal)

Dosing: load 15–20 mg/kg IV (can give additional 5–10 mg/kg); maintenance 1–5 mg/kg/day (or level-guided).
Contraindications/Cautions: respiratory depression, hypotension, porphyria; accumulation with hepatic failure.
Primary benefits: refractory status epilepticus; synergy with benzos.
ICU notes: may require airway control/vasopressors; enzyme inducer with many interactions.

Benzodiazepines (Lorazepam, Diazepam, Midazolam)

Emergency dosing: Lorazepam 4 mg IV (2 mg/min), repeat once in 10–15 min; Diazepam 5–10 mg IV q10–15 min (max 30 mg); Midazolam 10 mg IM if no IV.
Refractory infusion: Midazolam infusion per ICU protocol.
Cautions: respiratory depression, hypotension, delirium with prolonged use.
ICU notes: always first step in convulsive status epilepticus.

Topiramate (Topamax) — Oral only

Dosing (PO): 25–400 mg/day divided; go slow to avoid cognitive effects.
Cautions: metabolic acidosis, renal stones, angle-closure glaucoma, weight loss.
ICU notes: not for acute control; can be crushed/NG if needed.

Oxcarbazepine (Trileptal) — Oral only

Dosing (PO): 300 mg BID, titrate to 1200–2400 mg/day.
Cautions: hyponatremia (check Na), rash; cross-reactivity with carbamazepine.
ICU notes: no IV; not for status epilepticus.

Carbamazepine (Tegretol) — Oral only

Dosing (PO): often 200 mg BID, titrate to 800–1200 mg/day; monitor levels.
Cautions: hyponatremia, marrow suppression, strong enzyme inducer, HLA-B*1502 risk (SJS/TEN in certain ancestries).
ICU notes: avoid in acute setting; many drug interactions.

Lamotrigine (Lamictal) — Oral only

Dosing (PO): must titrate slowly (e.g., 25 mg/day and up) to avoid rash; adjust with valproate/enzyme inducers.
Cautions: SJS/TEN; interactions with valproate (increase levels).
ICU notes: not suitable for acute control; continuation med.

Zonisamide (Zonegran) — Oral only

Dosing (PO): 100–600 mg/day divided; slow uptitration.
Cautions: sulfonamide allergy, metabolic acidosis, stones, weight loss.
ICU notes: adjunct maintenance; not acute control.

Gabapentin / Pregabalin — Oral only

Dosing (PO): Gabapentin 300–3600 mg/day; Pregabalin 150–600 mg/day, both divided; renal adjust.
Cautions: sedation, ataxia; adjust for CrCl.
ICU notes: not for acute seizures; helpful for neuropathic pain.

Perampanel (Fycompa) — Oral only

Dosing (PO): 2–12 mg HS; adjust with enzyme inducers.
Cautions: irritability, aggression, dizziness; fall risk.
ICU notes: not acute; monitor behavior.